AF detection and management offers an opportunity for community pharmacy, says Helen Williams, consultant pharmacist specialising in CVD

You have known 68-year-old Trevor for many years. He is a regular visitor to your pharmacy for medication for his COPD and hypertension.

He comes for his flu jab and you check his blood pressure (BP) and pulse rate and rhythm at the same time. His BP is well controlled at 136/82mmHg but his pulse feels irregular and you note a pulse rate of 98 beats per minute. On questioning, he reports occasional palpitations over the past few months, especially when he is more active.

An irregular pulse is a sign of atrial fibrillation (AF), although this is not sufficiently sensitive or specific to make a diagnosis. A simple ectopic beat or two can also make the pulse rate feel irregular but is of little significance.

Trevor will need to understand that he may have an irregular heart rhythm that needs further investigation, so you should recommend that he sees his GP within the next few days for follow-up.

Trevor may want to know what the consequences of AF are, if this is confirmed. You can explain that AF can lead to an increased risk of stroke, but there are many effective treatments available to reduce that risk.

You should be careful to avoid causing unnecessary anxiety regarding the language you use but must be clear on the importance of him seeing his GP in a timely manner.

Next steps

Trevor’s GP should arrange an ECG to confirm the diagnosis of AF and should look for causes of AF that may be correctable, such as hyperthyroidism, infection or cardiac ischaemia. As a result, Trevor is likely to require blood tests.

Treatment

Trevor is at risk of experiencing an AF-related stroke, so anticoagulant therapy is indicated as this reduces the risk by about 65 per cent.

Trevor should be given warfarin or a DOAC, taking into account clinical parameters such as renal function and patient preferences. This will be lifelong therapy, so it is essential that he understands the rationale for his treatment and is willing and able to adhere to the prescription.

Trevor is an ideal candidate for the NMS as he may have questions about the therapy and concerns he would like to discuss but has not had the opportunity to raise with his GP. In addition to anticoagulant therapy, Trevor may need rate control therapy to control his heart rate and prevent his palpitations. A beta-blocker or rate-controlling calcium channel blocker is usually the first-line choice, with the dose increased to achieve a resting heart rate of 90 beats per minute.